Healthcare Provider Details

I. General information

NPI: 1023002383
Provider Name (Legal Business Name): WARREN G KRUCKMEYER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2005
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 BROWN ST
WAUCONDA IL
60084-1747
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 847-795-3350
  • Fax: 847-487-2841
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036067571
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: